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Kazeminia M, Rajati F, Rajati M. The effect of pelvic floor muscle-strengthening exercises on low back pain: a systematic review and meta-analysis on randomized clinical trials. Neurol Sci 2023; 44:859-872. [PMID: 36205811 DOI: 10.1007/s10072-022-06430-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/23/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Low back pain is a musculoskeletal disorder (MSD), and Kegel exercise is considered as one of the non-surgical management methods. Therefore, the present systematic review and meta-analysis aimed to estimate the results of randomized clinical trials (RCT) about the effect of pelvic floor muscle-strengthening exercises on reducing low back pain. METHODS: The present study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline (2020) to January 2022. The relevant studies were searched in the MagIran, SID, PubMed, Embase, Web of Science (WoS), Scopus, ClinicalTrials.gov databases and Google Scholar motor engine using related MeSH/Emtree terms, which were combined with free text word. The heterogeneity of the studies was checked using I2 statistic. RESULTS Finally, 19 RCTs with a sample size of 456 subjects in the intervention group and 470 in the control group were included in the meta-analysis. The low back pain intensity in the intervention group decreased up to 1.261 ± 0.213 (SMD ± 95% CI) with I2 = 87.60 more than that in the control group (P <0.001). The low back pain intensity in postpartum women decreased up to 1.614 ± 0.312 (95% CI) followed by pregnant women as 1.282 ± 0.479 (SMD ± 95% CI) more than that in other populations. But due to high the heterogeneity in all sub-groups (I2 > 80%) this result should be considered with caution. Meta-regression analysis showed the effect of pelvic floor muscle-strengthening exercises increased by increasing the year of publication, quality assessment score of the article, and the number of weeks of intervention (P<0.05). CONCLUSION Based on the results of the present meta-analysis, pelvic floor muscle-strengthening exercises significantly reduce the low back pain intensity. Therefore, these exercises can be regarded as a part of a low back pain management plan.
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Affiliation(s)
- Mohsen Kazeminia
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fatemeh Rajati
- Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mojgan Rajati
- Department of Obstetrics and Gynecology, School of Medicine, Motazedi Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Low Back Pain, Disability, and Quality of Life One Year following Intradiscal Injection of Autologous Bone Marrow Aspirate Concentrate. Stem Cells Int 2022; 2022:9617511. [PMID: 36579141 PMCID: PMC9792240 DOI: 10.1155/2022/9617511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/03/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Degenerative disc disease is a common cause of chronic low back pain. Surgical intervention is an invasive treatment associated with high costs. There is growing interest in regenerative medicine as a less invasive but direct disc treatment for chronic discogenic low back pain. Objective To evaluate clinical improvement of primary discogenic low back pain with intradiscal injection of autologous bone marrow aspirate concentrate (BMAC). Study Design. Prospective cohort study. Setting. Single, multiphysician center. Patients. 32 adult patients undergoing intradiscal injection of autologous BMAC for the treatment of primary discogenic low back pain. Interventions. Intradiscal injection of autologous BMAC. Main Outcome Measures. Primary outcome measure is visual analog back pain scale (VAS back pain). Secondary outcome measures include ODI, VAS leg pain, and EQ-5D-5L scores. Outcomes were compared from baseline to 1 year. Results Thirty-two patients (56.3% male) with a mean age of 45.9 years were enrolled, giving 92 treated levels. Mean VAS back and leg pain scores improved from 5.4 to 3.0 (p < 0.001) and 2.8 to 1.3 (p = 0.005), respectively. Mean ODI scores decreased from 33.5 to 21.1 (p < 0.001), and EQ-5D-5L scores improved from 0.69 to 0.78 (p = 0.001). Using established MCID values, 59.4% had clinically significant improvement in VAS back pain, 43.8% in VAS leg pain, and 56.3% in ODI scores. Conclusion Intradiscal injection of autologous BMAC significantly improved low back pain, disability, and quality of life at one year. This study suggests that intradiscal BMAC has the potential to be an effective nonsurgical treatment for chronic discogenic low back pain.
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Smith MM, Hayes AJ, Melrose J. Pentosan Polysulphate (PPS), a Semi-Synthetic Heparinoid DMOAD With Roles in Intervertebral Disc Repair Biology emulating The Stem Cell Instructive and Tissue Reparative Properties of Heparan Sulphate. Stem Cells Dev 2022; 31:406-430. [PMID: 35102748 DOI: 10.1089/scd.2022.0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This review highlights the attributes of pentosan polysulphate (PPS) in the promotion of intervertebral disc (IVD) repair processes. PPS has been classified as a disease modifying osteoarthritic drug (DMOAD) and many studies have demonstrated its positive attributes in the countering of degenerative changes occurring in cartilaginous tissues during the development of osteoarthritis (OA). Degenerative changes in the IVD also involve inflammatory cytokines, degradative proteases and cell signalling pathways similar to those operative in the development of OA in articular cartilage. PPS acts as a heparan sulphate (HS) mimetic to effect its beneficial effects in cartilage. The IVD contains small cell membrane HS-proteoglycans (HSPGs) such as syndecan, and glypican and a large multifunctional HS/chondroitin sulphate (CS) hybrid proteoglycan (HSPG2/perlecan) that have important matrix stabilising properties and sequester, control and present growth factors from the FGF, VEGF, PDGF and BMP families to cellular receptors to promote cell proliferation, differentiation and matrix synthesis. HSPG2 also has chondrogenic properties and stimulates the synthesis of extracellular matrix (ECM) components, expansion of cartilaginous rudiments and has roles in matrix stabilisation and repair. Perlecan is a perinuclear and nuclear proteoglycan in IVD cells with roles in chromatin organisation and control of transcription factor activity, immunolocalises to stem cell niches in cartilage, promotes escape of stem cells from quiescent recycling, differentiation and attainment of pluripotency and migratory properties. These participate in tissue development and morphogenesis, ECM remodelling and repair. PPS also localises in the nucleus of stromal stem cells, promotes development of chondroprogenitor cell lineages, ECM synthesis and repair and discal repair by resident disc cells. The availability of recombinant perlecan and PPS offer new opportunities in repair biology. These multifunctional agents offer welcome new developments in repair strategies for the IVD.
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Affiliation(s)
- Margaret M Smith
- The University of Sydney Raymond Purves Bone and Joint Research Laboratories, 247198, St Leonards, New South Wales, Australia;
| | - Anthony J Hayes
- Cardiff School of Biosciences, University of Cardiff, UK, Bioimaging Unit, Cardiff, Wales, United Kingdom of Great Britain and Northern Ireland;
| | - James Melrose
- Kolling Institute, University of Sydney, Royal North Shore Hospital, Raymond Purves Lab, Sydney Medical School Northern, Level 10, Kolling Institute B6, Royal North Shore Hospital, St. Leonards, New South Wales, Australia, 2065.,University of New South Wales, 7800, Graduate School of Biomedical Engineering, University of NSW, Sydney, New South Wales, Australia, 2052;
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Ye F, Xu Y, Lin F, Zheng Z. TNF-α suppresses SHOX2 expression via NF-κB signaling pathway and promotes intervertebral disc degeneration and related pain in a rat model. J Orthop Res 2021; 39:1745-1754. [PMID: 32816304 DOI: 10.1002/jor.24832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/13/2020] [Accepted: 08/18/2020] [Indexed: 02/04/2023]
Abstract
This study was conducted to verify the relative expression patterns of SHOX2 and its regulation by tumor necrosis factor alpha (TNF-α) during the development of intervertebral disc degeneration (IVDD). A rat disc-degeneration model was subjected to disc puncture (DP) and intradiscal injections with TNF-α to determine the roles of TNF-α and SHOX2 expression in IVDD in vivo. TNF-α and SHOX2 expression patterns in different degenerative rat nucleus pulposus (NP) tissues were measured by immunohistochemistry (IHC). The effects of TNF-α on IVDD were determined by magnetic resonance imaging (MRI) and pain development of wet-dog shakes (WDS) were blinded assessment by pain-behavior testing, respectively. Changes in TNF-α on SHOX2 expression were measured by Western blot analysis and real-time reverse transcription polymerase chain reaction (RT-PCR). The roles of nuclear factor-κB (NF-κB) and mitogen-activated protein kinase (MAPK) in TNF-α-mediated SHOX2 activation were studied using viral transfection, Western blot analysis, and real-time RT-PCR. In vivo, TNF-α accelerated the process of IVDD and suppressed SHOX2 expression; compared to the DP group, WDS was significantly increased in TNF-α intradiscal injection group at 2 to 6 weeks after puncture (P < .05); In NP cells, TNF-α negatively affected the IVDD-associated SHOX2 suppression. While TNF-α promotes IVDD through activation of both MAPK and NF-κB signaling, it seemed that only NF-κB signaling controlled the TNF-α-mediated SHOX2 suppression that is associated with IVDD. The results of this study indicated that TNF-α inhibits SHOX2 expression and has promoted effects on IVDD in the rat model, and these effects might be associated with through NF-κB signaling pathway and promotes IVDD and related pain in a rat model.
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Affiliation(s)
- Fubiao Ye
- Department of Orthopedic, Fujian Provincial Hospital, Shengli Clinical Medical College Affiliated to Fujian Medical University, Fuzhou, Fujian, China
| | - Yang Xu
- Department of Orthopedic, Fujian Provincial Hospital, Shengli Clinical Medical College Affiliated to Fujian Medical University, Fuzhou, Fujian, China
| | - Feiyue Lin
- Department of Orthopedic, Fujian Provincial Hospital, Shengli Clinical Medical College Affiliated to Fujian Medical University, Fuzhou, Fujian, China
| | - Zhaomin Zheng
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Li ZQ, Kong L, Liu C, Xu HG. Human Bone Marrow Mesenchymal Stem Cell-derived Exosomes Attenuate IL-1β-induced Annulus Fibrosus Cell Damage. Am J Med Sci 2020; 360:693-700. [PMID: 32771218 DOI: 10.1016/j.amjms.2020.07.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 04/25/2020] [Accepted: 07/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intervertebral disc degeneration (IDD) has high morbidity and high disability. Exosomes as a favorable candidate for IDD treatment is a hot spot of current research. METHODS Exosomes were obtained from bone marrow mesenchymal stem cells (BM-MSCs) of patients with non-open femoral fractures. Then, annulus fibrosus (AF) cells were treated with IL-1β, IL-1β combined with exosomes or IL-1β combined with exosomes and rapamycin. Flow cytometry and CCK-8 assay were performed to explore the apoptosis and cell proliferation. Quantitative real-time PCR and western blot were performed to detect the gene and protein expression. RESULTS Exosomes were obtained from BM-MSCs successfully. BM-MSC-derived exosomes suppressed IL-1β-induced inflammation and apoptosis and promoted cell proliferation of AF cells. BM-MSC-derived exosomes inhibited autophagy of AF cells by activating PI3K/AKT/mTOR signaling pathway. The effect of BM-MSC-derived exosomes on inflammation and apoptosis of AF cells was rescued by rapamycin. CONCLUSIONS In conclusion, our study revealed that BM-MSC-derived exosomes inhibited IL-1β-induced inflammation and apoptosis of AF cells by suppressing autophagy.
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Affiliation(s)
- Zhong-Qi Li
- Department of Spine Surgery, Medical College of Shandong University, Jinan, Shandong, People's Republic of China; Department of Spine Surgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, People's Republic of China
| | - Lei Kong
- Department of Spine Surgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, People's Republic of China
| | - Chen Liu
- Department of Spine Surgery, The First Affiliated Hospital of WanNan Medical College, Anhui, People's Republic of China
| | - Hong-Guang Xu
- Department of Spine Surgery, The First Affiliated Hospital of WanNan Medical College, Anhui, People's Republic of China.
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Chen S, Liu S, Ma K, Zhao L, Lin H, Shao Z. TGF-β signaling in intervertebral disc health and disease. Osteoarthritis Cartilage 2019; 27:1109-1117. [PMID: 31132405 DOI: 10.1016/j.joca.2019.05.005] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 05/02/2019] [Accepted: 05/14/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This paper aims to provide a comprehensive review of the changing role of transforming growth factor-β (TGF-β) signaling in intervertebral disc (IVD) health and disease. METHODS A comprehensive literature search was performed using PubMed terms 'TGF-β' and 'IVD'. RESULTS TGF-β signaling is necessary for the development and growth of IVD, and can play a protective role in the restoration of IVD tissues by stimulating matrix synthesis, inhibiting matrix catabolism, inflammatory response and cell loss. However, excessive activation of TGF-β signaling is detrimental to the IVD, and inhibition of the aberrant TGF-β signaling can delay IVD degeneration. CONCLUSIONS Activation of TGF-β signaling has a promising treatment prospect for IVD degeneration, while excessive activation of TGF-β signaling may contribute to the progression of IVD degeneration. Studies aimed at elucidating the changing role of TGF-β signaling in IVD at different pathophysiological stages and its specific molecular mechanisms are needed, and these studies will contribute to safe and effective TGF-β signaling-based treatments for IVD degeneration.
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Affiliation(s)
- S Chen
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - S Liu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - K Ma
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - L Zhao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - H Lin
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Z Shao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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Regenerative potential of human nucleus pulposus resident stem/progenitor cells declines with ageing and intervertebral disc degeneration. Int J Mol Med 2018; 42:2193-2202. [PMID: 30015833 DOI: 10.3892/ijmm.2018.3766] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/04/2018] [Indexed: 11/05/2022] Open
Abstract
Numerous studies have demonstrated the presence of resident nucleus pulposus stem/progenitor cells (NPSCs) in the tissue of the intervertebral disc (IVD). However, the cellular identity of NPSCs during IVD degeneration and ageing are poorly defined at present, despite significant progress in the understanding of NPSC biology. In the present study, NPSCs were isolated from human degenerated IVD and were characterized by flow cytometry, gene expression assays and proliferation and multipotency analysis. The results of the present study demonstrated that NPSCs isolated from human degenerated IVD may be divided into two groups according to the expression of mesenchymal stem cell (MSC) surface markers: The high expression of MSC surface markers group (H‑NPSCs) was highly positive for CD29, CD44, CD73, CD90 and CD105 at rates >95%, and the low expression of MSC markers surface markers group (L‑NPSCs), with the expression of CD29 and CD105 exhibiting individual variability, however, all at rates <95%. The donors for H‑NPSCs were aged <20 years, while the majority of donors for L‑NPSCs were aged >25 years, with one exception aged <20 years. The results highlighted that the low expression of MSC surface markers in NPSCs from aged and degenerated NP tissues were associated with a low rate of proliferation and reduced differentiation potential, as well as downregulation of the NP progenitor marker Tie2 and higher expression of NP cell‑specific markers. These findings demonstrated that the regenerative potential of human NPSCs declines with ageing and degeneration of the IVD.
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Riester SM, Lin Y, Wang W, Cong L, Ali AMM, Peck SH, Smith LJ, Currier BL, Clark M, Huddleston P, Krauss W, Yaszemski MJ, Morrey ME, Abdel MP, Bydon M, Qu W, Larson AN, van Wijnen AJ, Nassr A. RNA sequencing identifies gene regulatory networks controlling extracellular matrix synthesis in intervertebral disk tissues. J Orthop Res 2018; 36:1356-1369. [PMID: 29227558 PMCID: PMC5990467 DOI: 10.1002/jor.23834] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 12/04/2017] [Indexed: 02/04/2023]
Abstract
Degenerative disk disease of the spine is a major cause of back pain and disability. Optimization of regenerative medical therapies for degenerative disk disease requires a deep mechanistic understanding of the factors controlling the structural integrity of spinal tissues. In this investigation, we sought to identify candidate regulatory genes controlling extracellular matrix synthesis in spinal tissues. To achieve this goal we performed high throughput next generation RNA sequencing on 39 annulus fibrosus and 21 nucleus pulposus human tissue samples. Specimens were collected from patients undergoing surgical discectomy for the treatment of degenerative disk disease. Our studies identified associations between extracellular matrix genes, growth factors, and other important regulatory molecules. The fibrous matrix characteristic of annulus fibrosus was associated with expression of the growth factors platelet derived growth factor beta (PDGFB), vascular endothelial growth factor C (VEGFC), and fibroblast growth factor 9 (FGF9). Additionally we observed high expression of multiple signaling proteins involved in the NOTCH and WNT signaling cascades. Nucleus pulposus extracellular matrix related genes were associated with the expression of numerous diffusible growth factors largely associated with the transforming growth signaling cascade, including transforming factor alpha (TGFA), inhibin alpha (INHA), inhibin beta A (INHBA), bone morphogenetic proteins (BMP2, BMP6), and others. CLINICAL SIGNIFICANCE this investigation provides important data on extracellular matrix gene regulatory networks in disk tissues. This information can be used to optimize pharmacologic, stem cell, and tissue engineering strategies for regeneration of the intervertebral disk and the treatment of back pain. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1356-1369, 2018.
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Affiliation(s)
- Scott M. Riester
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Occupational and Environmental Medicine, HealthPartners, MN, USA
| | - Yang Lin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Wei Wang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Lin Cong
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, The First Hospital of China Medical University, No.155, Nanjing Bei Street, Shenyang, 110001, P. R. China
| | | | - Sun H. Peck
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, PA, USA
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | - Lachlan J. Smith
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, PA, USA
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | | | - Michelle Clark
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Paul Huddleston
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - William Krauss
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Mark E. Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Wenchun Qu
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
- Department of Anesthesiology Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
- Spine Center, Mayo Clinic, Rochester, MN, USA
| | - A. Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Vedicherla S, Buckley CT. Cell-based therapies for intervertebral disc and cartilage regeneration- Current concepts, parallels, and perspectives. J Orthop Res 2017; 35:8-22. [PMID: 27104885 DOI: 10.1002/jor.23268] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/08/2016] [Indexed: 02/04/2023]
Abstract
Lower back pain from degenerative disc disease represents a global health burden, and presents a prominent opportunity for regenerative therapeutics. While current regenerative therapies such as autologous disc chondrocyte transplantation (ADCT), allogeneic juvenile chondrocyte implantation (NuQu®), and immunoselected allogeneic adipose derived precursor cells (Mesoblast) show exciting clinical potential, limitations remain. The heterogeneity of preclinical approaches and the paucity of clinical guidance have limited translational outcomes in disc repair, lagging almost a decade behind cartilage repair. Advances in cartilage repair have evolved to single step approaches with improved orthopedic repair and regeneration. Elements from cartilage regeneration endeavors could be adopted and applied to harness translatable approaches and deliver a clinically and economically feasible regenerative surgery for back pain. In this article, we trace the developments behind the translational success of cartilage repair, examine elements to consider in achieving disc regeneration, and the need for surgical redesign. We further discuss clinical parameters, objectives, and coordination required to deliver improved regenerative surgery. Cell source, processing, and delivery modalities are key issues to be addressed in considering surgical redesign. Advances in biomanufacturing, tissue cryobanking, and point of care cell processing technology may enable intraoperative solutions for single step procedures. To maximize translational success a triad partnership between clinicians, industry, and researchers will be critical in providing instructive clinical guidelines for design as well as practical and economic considerations. This will allow a consensus in research ventures and add regenerative surgery into the algorithm in managing and treating a debilitating condition such as back pain. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:8-22, 2017.
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Affiliation(s)
- Srujana Vedicherla
- Trinity Centre for Bioengineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland.,School of Medicine, Trinity College Dublin, Ireland
| | - Conor T Buckley
- Trinity Centre for Bioengineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland.,Department of Mechanical and Manufacturing Engineering, School of Engineering, Trinity College Dublin, Ireland
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Wan S, Borland S, Richardson SM, Merry CL, Saiani A, Gough JE. Self-assembling peptide hydrogel for intervertebral disc tissue engineering. Acta Biomater 2016; 46:29-40. [PMID: 27677593 DOI: 10.1016/j.actbio.2016.09.033] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/22/2022]
Abstract
Cell-based therapies for regeneration of intervertebral discs are regarded to hold promise for degenerative disc disease treatment, a condition that is strongly linked to lower back pain. A de novo self-assembling peptide hydrogel (SAPH), chosen for its biocompatibility, tailorable properties and nanofibrous architecture, was investigated as a cell carrier and scaffold for nucleus pulposus (NP) tissue engineering. Oscillatory rheology determined that the system would likely be deliverable via minimally invasive procedure and mechanical properties could be optimised to match the stiffness of the native human NP. After three-dimensional culture of NP cells (NPCs) in the SAPH, upregulation of NP-specific genes (KRT8, KRT18, FOXF1) confirmed that the system could restore the NP phenotype following de-differentiation during monolayer culture. Cell viability was high throughout culture whilst, similarly to NPCs in vivo, the viable cell population remained stable. Finally, the SAPH stimulated time-dependent increases in aggrecan and type II collagen deposition, two important NP extracellular matrix components. Results supported the hypothesis that the SAPH could be used as a cell delivery system and scaffold for the treatment of degenerative disc disease. STATEMENT OF SIGNIFICANCE Lower back pain (LBP) prevalence is widespread due to an aging population and the limited efficacy of current treatments. As LBP is strongly associated with intervertebral disc (IVD) degeneration, it is thought that cell-based therapies could alleviate LBP by repairing IVD tissue. Various natural and synthetic biomaterials have been investigated as potential IVD tissue engineering scaffolds. Self-assembling peptide hydrogels (SAPHs) combine advantages of both natural and synthetic biomaterials; for example they are biocompatible and have easily modifiable properties. The present study demonstrated that a de novo SAPH had comparable strength to the native tissue, was injectable, restored the IVD cell phenotype and stimulated deposition of appropriate matrix components. Results illustrated the promise of SAPHs as scaffolds for IVD tissue engineering.
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Gruber HE, Riley FE, Hoelscher GL, Ingram JA, Bullock L, Hanley EN. Human annulus progenitor cells: Analyses of this viable endogenous cell population. J Orthop Res 2016; 34:1351-60. [PMID: 27249627 DOI: 10.1002/jor.23319] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 05/27/2016] [Indexed: 02/04/2023]
Abstract
Back pain and intervertebral disc degeneration have growing socioeconomic/health care impacts. Increasing research efforts address use of stem and progenitor cell-based replacement therapies to repopulate and regenerate the disc. Data presented here on the innate human annulus progenitor cells: (i) assessed osteogenic, chondrogenic and adipogenic potentials of cultured human annulus cells; and (ii) defined progenitor-cell related gene expression patterns. Verification of the presence of progenitor cells within primary human disc tissue also used immunohistochemical identification of cell surface markers and microarray analyses. Differentiation analysis in cell cultures demonstrated a viable progenitor cell pool within Thompson grades III-IV discs. Osteogenesis was present in 8 out of 11 cultures (73%), chondrogenesis in 8 of 11 (73%), and adipogenesis in 6 of 6 (100%). Immunolocalization was positive for CD29, CD44, CD105, and CD14 (mean values 80.2%, 81.5%, 85.1%, and 88.6%, respectively); localization of CD45 and CD34 was negative in disc tissue. Compared to controls, surgical discs showed significantly downregulated genes with recognized progenitor cell functions: TCF7L2 (2.7 fold), BMI1 (3.8 fold), FGF receptor 2 (2 fold), PAFAH1B1 (2.3 fold), and GSTP1 (9 fold). Compared to healthier grade I/II discs, grade III/IV discs showed significantly upregulated XRCC5 (3.6 fold), TCF7L2 (6 fold), GSTP1 (3.7 fold), and BMI1 (3 fold). Additional significant cell marker analyses showed expression of platelet-derived growth factor receptor alpha, CD90, CD73, and STRO-1. Statement of Clinical Significance: Findings provide the first identification of progenitor cells in annulus specimens from older, more degenerate discs (in contrast to earlier studies of healthier discs or nondegenerative specimens from teenagers). Findings also increase knowledge on progenitor cells present in the disc and suggest their value in potential future utilization for regeneration and disc cell therapy. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1351-1360, 2016.
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Affiliation(s)
- Helen E Gruber
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Calorina, 20226
| | - Frank E Riley
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Calorina, 20226
| | - Gretchen L Hoelscher
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Calorina, 20226
| | - Jane A Ingram
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Calorina, 20226
| | - Letitia Bullock
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Calorina, 20226
| | - Edward N Hanley
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Calorina, 20226
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12
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Yang T, Wang Y, Jiang S, Liu X, Yu Z. Hepatocyte growth factor-induced differentiation of bone mesenchymal stem cells toward hepatocyte-like cells occurs through nuclear factor-kappa B signaling in vitro. Cell Biol Int 2016; 40:1017-23. [PMID: 27249785 DOI: 10.1002/cbin.10630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 05/26/2016] [Indexed: 01/19/2023]
Abstract
Hepatocyte growth factor (HGF) is multifaceted cytokine that regulates proliferation, differentiation, morphology, and motility within numerous stem cells. More recently, HGF has been reported to induce the differentiation of bone mesenchymal stem cells (BMSCs) into mature hepatocytes, but the underlying biochemical and molecular signaling is largely unknown. We isolated BMSC from the bone marrow of rats, which were then cultured and exposed to HGF for 15 days. We subsequently assayed these cells for liver functionality and markers, and blocked NF-кB signaling at various stages of the pathway. The present results demonstrate that HGF induces the differentiation of BMSCs toward hepatocyte-like cells through the NF-кB signaling. More specifically, HGF upregulated the translocation of NF-кB to the nucleus.
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Affiliation(s)
- Tongxi Yang
- Department of Cell Biology, School of Basic Medicine, Qingdao University, Qingdao City, Shandong Province, 266000, China
| | - Yi Wang
- Department of Cell Biology, School of Basic Medicine, Qingdao University, Qingdao City, Shandong Province, 266000, China
| | - Shasha Jiang
- Department of Cell Biology, School of Basic Medicine, Qingdao University, Qingdao City, Shandong Province, 266000, China
| | - Xiaoping Liu
- Department of Histology and Embryology, School of Basic Medicine, Qingdao University, Qingdao City, Shandong Province, 266000, China
| | - Zhongjie Yu
- Department of Cell Biology, School of Basic Medicine, Qingdao University, Qingdao City, Shandong Province, 266000, China
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Xia J, Zhang H, Gao X, Guo J, Hou J, Wang X, Wang S, Yang T, Zhang X, Ge Q, Wan L, Cheng W, Zheng J, Chen X, Wu X. E-cadherin-mediated contact of endothelial progenitor cells with mesenchymal stem cells through β-catenin signaling. Cell Biol Int 2016; 40:407-18. [PMID: 26771770 DOI: 10.1002/cbin.10579] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 01/12/2016] [Indexed: 01/22/2023]
Abstract
Mesenchymal stem cells (MSCs) and endothelial progenitor cells (EPCs) are attached to each other in the bone marrow (BM) cavity and in in vitro cultures, and this adhesion has important physiological significance. We demonstrated that cell proliferation could be promoted when MSCs were co-cultured with EPCs, which was beneficial to angiogenesis, tissue repair, and regeneration. The adhesion of MSCs and EPCs could promote the pluripotency of MSCs, particularly self-renewal and multi-differentiation to osteoblasts, chondrocytes, and adipocytes. This study focused on the mechanism of adhesion between EPCs and MSCs. The results showed that E-cadherin (E-cad) mediated the adhesion of MSCs and EPCs through the E-cad/beta-catenin signaling pathway. The E-cad of EPCs occupied a dominant position during this process, which activated and up-regulated the beta-catenin (β-catenin) of MSCs to improve cohesion and exert their biological function.
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Affiliation(s)
- Jie Xia
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China.,Department of General Surgery, Xi'an Central Hospital, Xi'an, Shaanxi, 710003, China
| | - Hongwei Zhang
- Department of General Surgery, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Xiaopeng Gao
- Department of General Surgery, Xi'an Central Hospital, Xi'an, Shaanxi, 710003, China
| | - Jun Guo
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Jixue Hou
- Department of General Surgery, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Xiaoyi Wang
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Sibo Wang
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Tao Yang
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Xuyong Zhang
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Quanhu Ge
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Longfei Wan
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Wenzhe Cheng
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Jinpo Zheng
- The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
| | - Xueling Chen
- Department of Immunology, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832002, China
| | - Xiangwei Wu
- Department of General Surgery, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China.,Laboratory of Translational Medicine, School of Medicine, Shihezi University, Shihezi, Xinjiang, 832008, China
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Multipotent Mesenchymal Stem Cell Treatment for Discogenic Low Back Pain and Disc Degeneration. Stem Cells Int 2016; 2016:3908389. [PMID: 26880958 PMCID: PMC4737050 DOI: 10.1155/2016/3908389] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/18/2015] [Indexed: 01/07/2023] Open
Abstract
Low back pain with resultant loss of function, decreased productivity, and high economic costs is burdensome for both the individual and the society. Evidence suggests that intervertebral disc pathology is a major contributor to spine-related pain and degeneration. When commonly used conservative therapies fail, traditional percutaneous or surgical options may be beneficial for pain relief but are suboptimal because of their inability to alter disc microenvironment catabolism, restore disc tissue, and/or preserve native spine biomechanics. Percutaneously injected Multipotent Mesenchymal Stem Cell (MSC) therapy has recently gained clinical interest for its potential to revolutionarily treat disc-generated (discogenic) pain and associated disc degeneration. Unlike previous therapies to date, MSCs may uniquely offer the ability to improve discogenic pain and provide more sustained improvement by reducing disc microenvironment catabolism and regenerating disc tissue. Consistent treatment success has the potential to create a paradigm shift with regards to the treatment of discogenic pain and disc degeneration.
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15
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Allogeneic Articular Chondrocyte Transplantation Downregulates Interleukin 8 Gene Expression in the Degenerating Rabbit Intervertebral Disk In Vivo. Am J Phys Med Rehabil 2015; 94:530-8. [PMID: 25133623 DOI: 10.1097/phm.0000000000000194] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to investigate whether repopulating the degenerating intervertebral disk (IVD) with articular chondrocytes will decrease inflammation in the degenerating rabbit IVD. DESIGN This was a biologic study in a rabbit IVD-injury model in vivo. Dual cell tracking methods (infrared dye labeling and adenovirus transduction) were used to demonstrate the viability of allogeneic articular chondrocytes injected into degenerating rabbit IVDs. Interleukin 8 gene expression was determined via real-time polymerase chain reaction. Infiltrating inflammatory cells (macrophages, T cells, or neutrophils) were examined with immunohistochemistry. The IVDs were also examined by routine histology. RESULTS Articular chondrocytes labeled with infrared dye were detected in the degenerating IVDs at both 2 and 8 wks after injection. At the 2-wk time point, interleukin 8 gene expression was comparable in IVDs injected with chondrocytes and in intact disks as control (P = 0.647), whereas its expression in IVDs injected with saline increased 50-fold (P = 0.028). Transgene expression of red fluorescent protein, β-galactosidase, and human bone morphogenetic protein 7 diminished at 8 wks after injection. IVDs injected with chondrocytes overexpressing human bone morphogenetic protein 7 did not show lower interleukin 8 gene expression or improved histology. Macrophages were consistently detected by immunohistochemistry in the cartilage formed around the needle insertion sites in both the saline and chondrocyte groups, whereas neither T cells nor neutrophils were detected. CONCLUSIONS Allogeneic rabbit articular chondrocyte survived in the degenerating rabbit IVDs for at least 8 wks. Cell treatment resulted in reduced IVD inflammation but did not significantly improve IVD structure.
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Han I, Ropper AE, Konya D, Kabatas S, Toktas Z, Aljuboori Z, Zeng X, Chi JH, Zafonte R, Teng YD. Biological approaches to treating intervertebral disk degeneration: devising stem cell therapies. Cell Transplant 2015. [PMID: 26223943 DOI: 10.3727/096368915x688650] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Intervertebral disk (IVD) degeneration is a common, chronic, and complex degeneration process that frequently leads to back pain and disability, resulting in a major public health issue. In this review we describe biological therapies under preclinical or clinical development with an emphasis on stem cell-based multimodal approaches that target prevention and treatment of IVD degeneration. Systematical review of the basic science and clinical literature was performed to summarize the current status of devising biological approaches to treating IVD degeneration. Since the exact mechanisms underlying IVD degeneration have not yet been fully elucidated and conservative managements appear to be mostly ineffective, current surgical treatment focuses on removal of the pathological disk tissues combined with spinal fusion. The treatment options, however, often produce insufficient efficacy and even serious complications. Therefore, there have been growing demands and endeavors for developing novel regenerative biology-guided strategies for repairing the IVD via delivery of exogenous growth factors, introduction of therapeutic genes, and transplantation of stem cells, or combinatorial therapies. Overall, the data suggest that when applied under a recovery neurobiology principle, multimodal regimens comprising ex vivo engineered stem cell-based disks hold a high potential promise for efficacious clinical translations.
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Affiliation(s)
- Inbo Han
- Department of Neurosurgery, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
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17
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Wang Z, Perez-Terzic CM, Smith J, Mauck WD, Shelerud RA, Maus TP, Yang TH, Murad MH, Gou S, Terry MJ, Dauffenbach JP, Pingree MJ, Eldrige JS, Mohammed K, Benkhadra K, van Wijnen AJ, Qu W. Efficacy of intervertebral disc regeneration with stem cells - a systematic review and meta-analysis of animal controlled trials. Gene 2015; 564:1-8. [PMID: 25796605 DOI: 10.1016/j.gene.2015.03.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/13/2015] [Indexed: 12/25/2022]
Abstract
Management of intervertebral disc (IVD) degenerative disease is challenging, as it is accompanied by irreversible loss of IVD cells. Stem cell transplantation to the disc has shown promise in decelerating or arresting the degenerative process. Multiple pre-clinical animal trials have been conducted, but with conflicting outcomes. To assess the effect of stem cell transplantation, a systematic review and meta-analysis was performed. A comprehensive literature search was conducted through Week 3, 2015. Inclusion criteria consisted of controlled animal trials. Two reviewers screened abstracts and full texts. Disagreements were resolved by a third reviewer. Random effects models were constructed to pool standardized mean difference (SMD). Twenty two studies were included; nine of which were randomized. Statistically significant differences were found with the stem cell group exhibiting increased disc height index (SMD=3.64, 95% confidence interval (CI): 2.49, 4.78; p<0.001), increased MRI T2 signal intensity (SMD=2.28, 95% CI: 1.48, 3.08; p<0.001), increased Type II collagen mRNA expression (SMD=3.68, 95% CI: 1.66, 5.70; p<0.001), and decreased histologic disc degeneration grade (SMD=-2.97, 95% CI: -3.97, -1.97; p<0.001). There was statistical heterogeneity between studies that could not be explained with pre-planned subgroup analyses based on animal species, study designs, and transplanted cell types. Stem cells transplanted to the IVD in quadruped animals decelerate or arrest the IVD degenerative process. Further studies in human clinical trials will be needed to understand if such benefit can be translated to bipedal humans.
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Affiliation(s)
- Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - Carman M Perez-Terzic
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, MN 55905, USA
| | - Jay Smith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA
| | - William D Mauck
- Department of Anesthesiology Pain Division, Mayo Clinic, Rochester, MN 55905, USA
| | - Randy A Shelerud
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; Spine Center, Mayo Clinic, Rochester, MN 55905, USA
| | - Timothy P Maus
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Tai-Hua Yang
- Department of Biomedical Engineering, National Cheng Kung University, Taiwan; Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905, USA
| | - Mohammad Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - Shanmiao Gou
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; Department of Anesthesiology Pain Division, Mayo Clinic, Rochester, MN 55905, USA
| | - Marisa J Terry
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA
| | - Jason P Dauffenbach
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA
| | - Mathew J Pingree
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; Department of Anesthesiology Pain Division, Mayo Clinic, Rochester, MN 55905, USA
| | - Jason S Eldrige
- Department of Anesthesiology Pain Division, Mayo Clinic, Rochester, MN 55905, USA
| | - Khaled Mohammed
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - Khalid Benkhadra
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Wenchun Qu
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; Department of Anesthesiology Pain Division, Mayo Clinic, Rochester, MN 55905, USA; Spine Center, Mayo Clinic, Rochester, MN 55905, USA.
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18
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Disc cell therapies: critical issues. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23 Suppl 3:S375-84. [PMID: 24509721 DOI: 10.1007/s00586-014-3177-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 12/02/2013] [Accepted: 01/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Disc cell therapies, in which cells are injected into the degenerate disc in order to regenerate the matrix and restore function, appear to be an attractive, minimally invasive method of treatment. Interest in this area has stimulated research into disc cell biology in particular. However, other important issues, some of which are discussed here, need to be considered if cell-based therapies are to be brought to the clinic. PURPOSE Firstly, a question which is barely addressed in the literature, is how to identify patients with 'degenerative disc disease' who would benefit from cell therapy. Pain not disc degeneration is the symptom which drives patients to the clinic. Even though there are associations between back pain and disc degeneration, many people with even severely degenerate discs, with herniated discs or with spinal stenosis, are pain-free. It is not possible using currently available techniques to identify whether disc repair or regeneration would remove symptoms or prevent symptoms from occurring in future. Moreover, the repair process in human discs is very slow (years) because of the low cell density which can be supported nutritionally even in healthy human discs. If repair is necessary for relief of symptoms, questions regarding quality of life and rehabilitation during this long process need consideration. Also, some serious technical issues remain. Finding appropriate cell sources and scaffolds have received most attention, but these are not the only issues determining the feasibility of the procedure. There are questions regarding the safety of implanting cells by injection through the annulus whether the nutrient supply to the disc is sufficient to support implanted cells and whether, if cells are able to survive, conditions in a degenerate human disc will allow them to repair the damaged tissue. CONCLUSIONS If cell therapy for treatment of disc-related disorders is to enter the clinic as a routine treatment, investigations must examine the questions related to patient selection and the feasibility of achieving the desired repair in an acceptable time frame. Few diagnostic tests that examine whether cell therapies are likely to succeed are available at present, but definite exclusion criteria would be evidence of major disc fissures, or disturbance of nutrient pathways as measured by post-contrast MRI.
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